General Principles of Periodontal Surgery

CONTENTS
OUTPATIENT SURGERY Preparation of the Patient Possible emergencies during outpatient periodontal surgery Measures to Prevent Transmission of Infection Sedation and Anesthesia Tissue Management Hemostasis Periodontal Dressings (Periodontal Packs) Instructions for the Patient after Surgery The First Postoperative Week

 Removal of the Periodontal Pack and Return Visit Care Care of the Mouth between Periodontal Surgery Procedures Management of Postoperative Pain HOSPITAL PERIODONTAL SURGERY Indications The Operation Postoperative Instructions

INTRODUCTION
The treatment of periodontal diseases encompasses a vast array of nonsurgical and surgical techniques aimed at the elimination of infection and inflammation to establish a healthy periodontium. Nonsurgical therapy often may be sufficient to eliminate the signs and symptoms of mild periodontal diseases. However, cases or sites with moderate to advanced disease often continue to show signs of inflammation after a nonsurgical approach. When periodontal probing depths are sufficiently deep, nonsurgical treatment may be ineffective in establishing health or preventing recurrence of disease. In such cases, gaining surgical access to the various components of the periodontium allows an opportunity for more thorough root debridement and establishment of an oral environment easier to maintain by both the patient and the dental care provider to aid in restoring periodontal health.
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 In addition, surgical treatment provides an opportunity to reconstruct destroyed periodontal tissues and to correct the variety of mucogingival and anatomic anomalies that may present. In essence, periodontal surgery is an irreplaceable therapeutic modality that must be mastered to effectively treat the dental health problems that many patients have.

Objectives of surgical treatment

1. Access to roots and alveolar bone -enhance visibility -increase scaling and root planning effectiveness -less tissue trauma 2. Modification of osseous defects -establish physiologic architecture of hard tissues through regeneration or resection -augment alveolar ridge defects 3. Repair or regeneration of the periodontium 4. Pocket reduction -enhance maintenance by patient and therapist -improve long-term stability
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5. Provide acceptable soft tissue contours - enhance plaque control and maintenance -improve esthetics (Rosling et al. 1976, Nyman et al.1977, Axelsson and Lindhe 1981)

Preparation of the Patient

Almost every patient undergoes the so-called initial or preparatory phase of therapy, which basically consists of thorough scaling and root planing and removing all irritants responsible for the periodontal inflammation. These procedures: 1) eliminate some lesions entirely 2) render the tissues more firm and consistent, thus permitting a more accurate and delicate surgery; and 3) acquaint the patient with the office and the operator and assistants, thereby reducing the patient's apprehension and fear.

BRUCE L. PIHLSTROM, RICHARD B, MCHUOH, THOMAS H. OLIPHANT AND CESAR ORTIZ-CAMPOS, 1983 Aim: Comparison of surgical and non surgical treatment of periodontal disease: A review of current studies and additional results after 6 1/2 years Abstract. Many well designed clinical studies have established the effectiveness of periodontal therapy, Surgical procedures have been shown to be effective in treating periodontitis when followed by appropriate maintenance care, Scaling and root planing alone have recently been compared to scaling and root planing plus soft tissue surgery in several longitudinal trials. A review of the literature indicates several important findings including a loss of clinical attachment following flap procedures for shallow (1-3 mm) pockets and no clinically significant loss after scaling and root planing. These studies also generally report either a gain or maintenance of attachment level for both procedures in deeper pockets (>4 mm).
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 For these pockets, neither procedure has been shown to be uniformly superior with respect to attachment gain. All reports indicate that both treatment methods result in pocket reduction. However, the literature also indicates that scaling and root planing combined with a flap procedure results in greater initial pocket reduction than does scaling and root planing alone. This difference in degree of pocket reduction between procedures tends to decrease beyond 1-2 years. It has been shown that both treatment methods result in sustained decreases in gingivitis, plaque and calculus and neither procedure appears to be superior with respect to these parameters.

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 Becker, Caffesse, Kerry et al in 2001 conducted a 5 year longitudinal study comparing scaling and root planing, osseous surgery and modified Widman procedures for treating periodontal diseases. Methods: 16 adult patients with moderate to advanced periodontal disease were treated with initial scaling and oral hygiene procedures in a private practice. Posthygiene data were used to compare changes in plaque and gingival indices, probing depyh, clinical attachment levels and recession. Conclusion: this 5-year clinical trial demonstrates that with good patient maintenance excellent clinical results can be achieved with various methods of treatment.

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Reevaluation after Phase I Therapy The reevaluation phase consists of probing and reexamining all the pertinent findings that previously indicated the need for the surgical procedure. Persistence of these findings confirms the indication for surgery. The number of surgical procedures, expected outcome, and postoperative care necessary are all decided beforehand. These are discussed with the patient and a final decision is made, incorporating any necessary adjustments to the original plan.

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Indications for surgical treatment

Accessibility for proper scaling and root planing. Area conducive to plaque control Pocket depth reduction Correction of gross gingival aberrations Shift of the gingival margin to a position apical to plaque-retaining restorations Facilitate proper restorative therapy

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Contraindications for surgical treatment

Uncontrolled medical conditions: Unstable angina Uncontrolled hypertension Uncontrolled diabetes Myocardial infarction or stroke within 6 months Poor plaque control High caries rate

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Premedication
For patients who are not medically compromised, the value of administering antibiotic routinely for periodontal surgery had not been clearly demonstrated. (Murphy NC, 1979) Examination of the patient with a history of medical problems should be more extensive than that associated with the normal healthy patient. Physical assessment should include evaluation of the patients general appearance like weight, posture, skin, and nails, blood pressure and temperature, pulse rate, respiratory rate, a thorough head and neck inspection including assessment of lymph nodes.

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Diabetes
In patients with well controlled diabetes, no extra specific treatment is required for routine periodontal therapy including prophylaxis. Morning appointments are recommended because cortisol levels are highest at this time and will provide the best blood glucose level. Patient should be instructed that morning meal should not be skipped. (Wray, 2011) The type 1 diabetes patient should not be scheduled immediately after an insulin injection because this may result in a hypoglycemic episode. Special care should be taken while administering local anesthesia.

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 In the moderately-controlled diabetic patient, if a major procedure is planned like flap surgery, an antibiotic should be prescribed following the surgery. After surgery the patients food intake should include the proper caloric content and protein/carbohydrate/fat ratio to maintain glucose balance. In the uncontrolled diabetic patient, only acute dental infection should be treated on emergency basis.

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 Antibiotics should be prescribed following treatment and monitored carefully for its efficacy. Intervention by physician is recommended for more complicated dental treatment because precise insulin management and post treatment care with respect to infection and body electrolyte balance may be needed. (Lalla RV, D'Ambrosio JA., 2001)

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Infective Endocarditis
In 2007, the American Dental Association and its Council on Scientific Affairs published a position paper that provides newly revised guidelines for the prevention of infective endocarditis (IE). These guidelines reflected current research assessing dental procedure related bacteremia, endocarditis, and the most common pathogens associated with the condition. The new guidelines reduce the classes of patients for whom antibiotic prophylaxis is recommended because the risk of morbidity resulting from antibiotic use outweighs its probable advantages

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 Multiple studies suggest that periodontal flap surgery, scaling, root planing, deep curettage can cause a bacteremia. But because of potential allergy, resistance, and cost-effectiveness, among other factors, the researchers have restricted the classes of patients for whom short-term antibiotic prophylaxis before dental procedures is recommended. (Smith A, et al, 2009)

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 Best practice includes the following American Dental Association, American Medical Association, and American Heart Association recommended prophylactic antibiotic regimen for the above conditions in the year 2007 as follows: Able to take oral medication: Amoxicillin 2 g (50 mg/kg) Unable to take oral medication: Ampicillin 2 g IM or IV (50 mg/kg IM or IV); Cefazolin or ceftriaxone 1 g IM or IV (50 mg/kg IM or IV) Allergic to penicillin or ampicillin: Cephalexin 2 g (50 mg/kg); Clindamycin 600 mg (20 mg/kg); Azithromycin or clarithromycin 500 mg (15 mg/kg) Allergic to penicillin or ampicillin and unable to take oral medication: Cefazolin or ceftriaxone 1 g IM or IV (50 mg/kg IM or IV); Clindamycin 600 mg IM or IV (20 mg/kg IM or IV).
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Ischemic Heart Disease with Angina

The patient with mild or moderate angina should be reminded to have with them their nitroglycerin tablets handy in case of an attack during periodontal treatment. The periodontitst should always have an updated stock of such emergency medications in his clinic. Additionally, oxygen deprivation in the patient with severe ischemic disease and angina can be avoided by delivery of oxygen via nasal cannula at 3L/min during periodontal treatment on precautionary basis. Anticholinergic drugs used to reduce salivary flow during long periodontal surgical procedures should be avoided because of the increased risk of pneumonia in patients with concomitant pulmonary edema. (Shuman SK. , 1990)

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Myocardial Infarction
Although relatively rare in the dental setting, cardiac arrest as a result of myocardial infarction (MI) can occur. In patients with a history of MI, any periodontal treatment should be pursued after at least 6 months of the cardiac event. The patients physician should be consented prior to treatment and proper knowledge regarding the patients current cardiac status should be sought . As with the ischemic patient, short morning appointments are best. The combination of an MI with congestive heart failure increases risk to the patient so only emergency treatment should be provided in such conditions unless and until physician gives the consent of normal health.

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 The onset of chest pain and shortness of breath during treatment warrants discontinuation of the procedure and immediate medical consultation or hospitalization. Several other considerations related with cardiac instability are imperative to consider. For example, a patient post MI may be on anticoagulant and the dose may need to be reduced if periodontal surgery is necessary. But still this point is matter of controversy. Even prolonged aspirin use can affect bleeding time. (Wilson et al, 2007) Potential complications can be avoided by acquiring a prothrombin time on the day of surgery to verify the patients ability to clot. In patients with pacemakers with metal, electro-cautery and the use of a magneto-strictive scaler should be avoided.
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Congestive Heart Failure

The challenges in treating the patient with congestive heart failure are several. The condition is often confounded by hypertension, a history of MIs, thyrotoxicosis, renal failure and chronic obstructive pulmonary disease (COPD). Antibiotics need to be prescribed following treatment to prevent infection. The amount of epinephrine delivered can be a significant confounder of the disease. A periodontist treating the patient with congestive heart failure should be prepared for potential complications.

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 Consequently, in the patient with multiple co-morbid conditions, only urgent dental needs should be provided. For the patient who is deemed stable and without significant complications, routine prophylaxis can be performed. Prior to treatment, a prothrombin time should be obtained, and, during treatment, the patient should be placed in an upright position to prevent additional pulmonary fluid collection.

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Drug Reactions
With the aging of the population, more and more people are taking single and multiple drug regimens for medically complex problems. Some of these medications can interact with drugs typically prescribed by periodontists, over-the-counter (OTC) or naturopathic preparations taken by the patient or even habit like alcohol consumption. Prescribed medications can cause a spectrum of allergic reactions and secondary intraoral effects such as gingival hyperplasia and other mucosal pathology. (Hersh E, Moore P. ,2004)

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 Medications are usually prescribed by periodontists that can be problematic in the patient taking medication for systemic disease: anesthetics, pain medications, and antibiotics. The severity rating for drugs within these classes varies from major, moderate and minor. The risk of drug interactions is dependent on patients age, gender and relative health.

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Local anaesthesia
Local anesthetics can be associated with toxicity (central nervous system and cardiac problems), allergy, hemoglobin abnormality (methemoglobinemia). Similarly nonselective -blockers may result in acute hypertension. Such an interaction is most likely to occur with intravascular injection, but the initial dose of a dental anesthetic injected via a cartridge that has 1:100,000 epinephrine has been recommended to only involve one-half the cartridge initially, with the patient monitored closely during subsequent injections. An excessive dose of prilocaine combined with dapsone can lead to methemoglobinemia. (Becker DE, Reed KL ,2006)

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Pain killers
Non Selective Anti Inflammatory Drugs are typically used for moderate pain, including pretreatment and post-treatment periodontal pain especially after the periodontal surgery. Their long-term use has been linked with gastrointestinal problems, including bleeding, ulceration, kidney damage and cardiovascular problems. In addition, blood pressure medication may also be compromised by coprescription of NSAIDs.

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Antibiotics
Antibiotics of concern for periodontist include the tetracyclines, metronidazole, erythromycin, etc. The alcoholic patient prescribed metronidazole may experience headache, palpitation, and nausea. This antibiotic also increases blood lithium levels in the patient using the drug to manage bipolar disorder by inhibiting renal excretion. This can lead to confusion, ataxia, and renal damage.

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Patients on digoxin (digitalis) for atrial flutter, atrial fibrillation, or congestive heart failure, the blood drug level may be elevated when erythromycin or tetracyclines are prescribed which can lead to increased salivation, visual disturbances, and arrhythmias. (Rose LF, et al. , 2002) In patients taking the anticoagulants like warfarin and anisindione to prevent emboli, a prescription of tetracyclines or other broad-spectrum antibiotic may modify vitamin K synthesize in the gut and, in the lack of vitamin K supplementation, could increase the risk of bleeding and hematuria. (K Ganda,2006)

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 Doxycycline used in periodontal treatment very commonly like Atridox is not recommended in women who are pregnan breastfeeding or in children under the age of 8 because of potential bone and tooth development abnormalities. Clinical studies suggest that this medication alters estrogen and progestin in birth control preparations, potentially rendering the oral contraceptive ineffective. This drug interaction has also been reported with penicillin, erythromycin, tetracycline, and cotrimoxazole, although the failure of oral contraceptives when coupled with these antibiotics remains controversial. (Wray, 2011)

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Smoking Patients should be clearly informed of this fact and requested to quit or stop smoking for a minimum of 3 to 4 weeks after the procedure. For patients who are unwilling to follow this advice, an alternate treatment plan not including highly sophisticated techniques such as regenerative procedures and mucogingival and esthetic techniques should be considered.

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Informed Consent The patient should be informed at the time of the initial visit about the diagnosis, prognosis, the different possible treatments with their expected results, and all pros and cons of each approach. At the time of surgery, the patient should again be informed, verbally and in writing, of the procedure to be performed, and he or she should indicate agreement by signing the consent form.

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Possible emergencies during outpatient periodontal surgery

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MEASURES TO PREVENT TRANSMISSION OF INFECTION

Implementation and adherence to infection control practices are the keys to preventing the transmission of healthcare associated infections, including respiratory diseases spread by droplet or airborne routes. Recommended infection control practices include the following: 1) Hand hygiene; 2) Standard precautions/transmission-based precautions (Contact, Droplet, Airborne); and 3) Respiratory hygiene. (Massachusetts Department of Public Health,2007)

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Hand Hygiene

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Droplet Precautions

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Contact precautions

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Airborne Infection Isolation

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Respiratory Hygiene/Cough Etiquette

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Local anesthesia in periodontal surgery

For the past 20 years, the primary local anesthetics used in dentistry are those classified as amides. Lidocaine and mepivacaine, two of the most commonly used dental anesthetic agents, have a 50-year history of effectiveness and safety in providing regional anesthesia for dental therapies. Practitioners prefer the amide local anesthetic agents over the ester agents (ie, procaine and propoxycaine) because amides more rapidly and reliably produce profound surgical anesthesia. (Yagiela J, Malamed SF, 1998)

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Vasoconstrictor
Prolongs the duration of an anesthetic agent by decreasing the blood flow in the immediate area of the injection. Decreases bleeding in the area during surgical procedures. Types: Epinephrine Levonordefrin Norepinephrine

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Epinephrine Nor Levonordefr Phenylephri epinephrine ine ne

Felypressen

RS

Bronchodila tion
Mild stimulation Very high High Less

Mild bronchodilat ion

Mild stimulation 25% Less More 15% Lesser Higher Highest 5%

CNS Potency Toxicity Stability

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Long-acting amide anesthetics: bupivacaine and etidocaine

Although both bupivacaine and etidocaine may provide adequate surgical anesthesia, they are most useful for postoperative pain management. Clinical trials have shown that bupivacaine has a slightly longer onset time than conventional anesthetics. (Moore PA, 1984) The profundity of anesthesia, however, appears to be comparable. Onset times and profundity are optimized when preparations of bupivacaine include epinephrine. (Laskin et al, 1977)

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 Etidocaine, although less well studied in dentistry, appears to have a slight advantage over bupivacaine with regard to onset times. Onset times for etidocaine have been found to be slightly more rapid than bupivacaine (less than 1 minute difference) when the agents were compared in endodontics and oral surgery. (Dunsky JL, Moore PA, 1984) The profundity of mandibular anesthesia provided by etidocaine with epinephrine appears to be equivalent to conventional agents. The profundity of etidocaine anesthesia following maxillary infiltrations may be somewhat less. (Moore PA, Dunsky JL, 1983)

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 Bupivacaine and etidocaine have been used in the overall management of chronic pain either as symptomatic, diagnostic, or definitive therapy. Prolonged anesthesia and pain relief may facilitate physical therapy of certain skeletal muscle disorders. Some myofascial pain dysfunction syndromes may benefit from injection of a long-acting local anesthetic into trigger points. Injections of long-acting agents, sometimes repeatedly over a course of weeks, may be useful in stimulating complete recovery from postherpetic neuralgias and reflex sympathetic dystrophies. (Burney RG, Moore PA, Duncan GH, 1983)
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Tissue Management
Operate gently and carefully. In addition to being most considerate to the patient, this is also the most effective way to operate. Tissue manipulation should be precise, deliberate, and gentle. Thoroughness is essential, but roughness must be avoided because it produces excessive tissue injury, causes postoperative discomfort, and delays healing.

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 Observe the patient at all times. It is essential to pay careful attention to the patient's reactions. Facial expressions, pallor, and perspiration are some distinct signs that may indicate the patient is experiencing pain, anxiety, or fear. The doctor's responsiveness to these signs can be the difference between success and failure.

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 Be certain the instruments are sharp. Instruments must be sharp to be effective; successful treatment is not possible without sharp instruments. Dull instruments inflict unnecessary trauma due to poor cutting and excessive force applied to compensate for their ineffectiveness. A sterile sharpening stone should be available on the operating table at all times.

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Hemostasis
Hemostasis is an important aspect of periodontal surgery because good intraoperative control of bleeding permits an accurate visualization of the extent of disease, pattern of bone destruction, and anatomy and condition of the root surfaces. It provides the operator with a clear view of the surgical site, which is essential for wound debridement and scaling and root planing. In addition, good hemostasis also prevents excessive loss of blood into the mouth, oropharynx, and stomach.

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 Periodontal surgery can produce profuse bleeding, especially during the initial incisions and flap reflection. After flap reflection and removal of granulation tissue, bleeding disappears or is considerably reduced. Typically, control of intraoperative bleeding can be managed with aspiration. Continuous suctioning of the surgical site with an aspirator is indispensable for performing periodontal surgery. Application of pressure to the surgical wound with moist gauze can be a helpful adjunct to control site specific bleeding. Intraoperative bleeding that is not controlled with these simple methods may indicate a more serious problem and require additional control measures.
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 Excessive hemorrhaging following initial incisions and flap reflection may be due to laceration of venules, arterioles, or larger vessels. Fortunately, the laceration of medium or large vessels is rare because incisions near highly vascular anatomic areas such as the posterior mandible (lingual and inferior alveolar arteries), and the posterior, midpalatal regions (greater palatine arteries) are avoided in incision and flap design. However, even when all anatomic precautions are taken, it is possible to cause bleeding from medium or large vessels because anatomic variations do occur and may result in inadvertent laceration.

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 If a medium or large vessel is lacerated, a suture around the bleeding end may be necessary to control hemorrhage. Pressure should be applied through the tissue to determine the location that will stop blood flow in the severed vessel. Then a suture can be passed through the tissue and tied to restrict blood flow. It is also possible to have excessive bleeding from a surgical wound due to incisions across a capillary plexus. Minor areas of persistent bleeding from capillaries can be stopped by applying cold pressure to the site with moist gauze (soaked in sterile ice water) for several minutes.

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 The use of a local anesthetic with a vasoconstrictor may also be useful in controlling minor bleeding from the periodontal flap. Both of these methods act via vasoconstriction, thus reducing the flow of blood through incised small vessels and capillaries. This action is relatively short lived and should not be relied on for long-term hemostasis. It is important to avoid the use of vasoconstrictors to control bleeding prior to sending a patient home. If a more serious bleeding problem exists or a firm blood clot is not established, bleeding is likely to reoccur when the vasoconstrictor has metabolized and the patient is no longer in the office. For slow, constant blood flow and oozing, hemostasis may be achieved with hemostatic agents.
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Absorbable Hemostatic Agents

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Periodontal Dressings (Periodontal Packs)

HISTORY OF PERIODONTAL PACKS 1923 Dr A W Ward- Wonder pak,consist of - Zno Eugenol mixed with Alcohol , pine oil, Asbestos fibers 1942 Box and Ham use of Zno Eugenol dressing to perform chemical curettage in treatment of NUG tannic acid was included for haemostasis and astringency- thymol was used as an astringent . 1943 Orban - Zno Eugenol + Paraformaldehyde to perform Gingivectomy by chemosurgery. This dressing caused extensive necrosis of the gingival and bone and was left to promote abscess formation by blockage of exudate.

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 1947 Bernier and Kaplan for wound protections. 1962 - Blanquie control post operative bleeding- splint loose teeth prevent reestablishment of pocket desensitize cementum 1964 Gold splint teeth, as it was cement dressing that set hard. 1964 - Weinreb and Shapiro - Zno Eugenol impregnated cords into periodontal pockets, but found to be less effective than gingevectomy. 1969 - Baer et al stated that primary purpose of a dressing patient comfort, protect wound from further injury during healing hold flap in position. They pointed that the dressing should not be used to control postoperative bleeding, nor to splint teeth .

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USES OF PERIODONTAL DRESSING

Provide mechanical protection for the surgical wound and therefore facilitate healing . Enchancement of patient comfort . Prevents post operative bleeding by maintaining the initial clot in place. Maintainance of debris free area. Control of bleeding Supports mobile teeth during healing Helps in shaping or molding the newly formed tissue Provide patient comfort by isolating area from external irritations or injuries.

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Physical Properties of Dressing

The dressing should be soft but have enough plasticity and flexibility to facilitate its placement in operated area and to allow proper adaptation. The dressing should set within a reasonable time ?After setting it should have sufficient rigidity The dressing should have smooth surface The dressing should have bactericidal property The dressing should not interfere with healing The dressing should have dimensional stability The dressing should not induce reaction The dressing should have acceptable taste.

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 The two most widely used type of dressing materials are: Zinc oxide eugenol Zinc oxide non-eugenol In addition, cyanoacrylates, tissue conditioners, collagen sponges and photo curing materials are also available. Zinc oxide eugenol dressing contain 40 -50 % eugenol, increases in amounts as zinc eugenate decomposes. It has been shown to cause tissue necrosis and delayed healing.

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 Radden 1992 found that free eugenol caused a marked inflammatory reaction , delayed healing and tissue necrosis. Asbestos was found to have the potential for causing asbestos lung cancer and tannic acid cause liver damage when absorbed systemically Baer et al 1960 described the use of a non - eugenol dressings containing zinc oxide, bacitracin and hydrogenated fat. The material did not set to hard consistency as do eugenol dressings, and bacitracin was believed to aid in healing.

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TYPES OF DRESSINGS
A. Zinc oxide Eugenol Dressing (hard pack) Brand Names: Wonder-Pak , by Ward 1923 POWDER ZnO- Resin LIQUID Eugenol,

Tannic acid Cellulose fibers Zinc acetate Asbestos

Vegetable oil Thymol

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Disadvantages: Unpleasantness Spicy taste Burning sensation Lack of smoothness Difficulty with adaptation Frequency of fracture Crazing of acrylic materials

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Non-Eugenol Dressings (Soft Pack) Brand names Coe-Pak Ingredients: Oxides of various metals zinc oxide Oil plasticity Gum cohesiveness Lorothidol fungicide

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 Collacote is a collagen dressing which contains type I collagen and is derived from bovine tendon. It is a resorbable dressing that is used to cover wounds especially platal graft sites. Tissue conditioners like methacrylate gels have also been used as a dressing for periodontal wounds. They are used primarily as tissue conditioners and denture liners as they are soft and resilient.

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 Cyanoacrylates were introduced as an alternative to suturing, as a surface adhesive and to be used as a periodontal dressing. It has the unique ability to cement together moist, lining surfaces.

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 Watts et al in 1980 conducted an in vitro study on the adhesion of periodonal dressings (Coe-pak, Peripacc and Wonderpak) to enamel . Viscosty of the 3 types of dressing marterials when evaluated revealed that none of them exhibited the ideal flo properties during manipulation or adaptation. Coe-pak was shown to have better adhesive properties than Wondrpak, while peripac did not show any adhesive strength.

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Controversies with use of periodontal dressing

On wound healing Tissue irritating properties of periodontal dressings mainly involve comparison of eugenol containing and non-eugenol containing periodontal dressings. Eugenol is known to be an obtudant, and hence included in periodontal dressing to promote healing and patient comfort. However, some free eugenol that remains and increases as zinc eugenolate decomposes, is said to cause a marked inflammatory reaction, delayed healing and necrosis of tissue. Haugen, 1979

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 Bone tissue response when evaluated, showed that all the dressings provoked reactions in bone, the strongest elicited by eugenol containing dressing materials. Studies on cell cultures showed that both eugenol and non-eugenol containing materials can be cytotoxic when tested against the LA cells, fibroblasts and polymorphonuclear leukocytes. Eugenol dressings are found to inhibit fibroblast proliferation to a greater extent. Thease cell cultures are of limited use as the cytotoxic components are diluted in mouth by saliva, blood and cellular defense components. Kreth, Zimmermann,1966

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 Effects of various antimicrobial agents in periodontal dressings ZOE dressings have shown to have antibacterial effect against streptococci, micrococcus and candida albicans in vitro. In vivo, they have been shown to sterilize the base of pocket. Various antimicrobial agents- terramycin, bacitracin, achromycin, antibiotics and corticosteroids have been added to reduce infections and to promote healing of surgically treated wounds.

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 The addition of antibiotics is of concern as its application may sensitize the patient to the agent, and also components of the dressing may inactivate the antibiotic. Overgrowth of candida species has also been observed following the inclusion of antibiotics. (Romanow, 1964) Chlorhexidine use in periodontal dressing may promote healing by decreasing the bacterial colonization of the wound.

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 Sensitization and allergy Case reports have shown allergic reaction to components of periodontal dressing. Presence of tannin, rosin and terramycin have shown to induce allergic reactions and was thought to be related to the leaching of these components. The signs of allergy include- burning sensation of buccal mucosa and tongue, erythema, vesicle formation and edema. (Sachs et al, 1969)

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Application of Hard and Soft Periodontal Dressing

A. Hard Pack
Mix maximum amount of powder into the liquid to achieve a putty mix Consistency is firm and thick B. Soft Pack Extrude equal lengths & quickly mix together with tongue blade until blended Use vaseline on gloves to form pack If there are open embrasures with missing papillae or recession, use small sections of the dressing to mold into wedge shapes to press interproximally.

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 Apply 1 U-Strip starting from distal and placing on the facial & lingual Press interproximally and with a plastic instrument adapt around the gingival surface and interproximal areas to gain retention and create festooning For protection & promotion of healing, the dressing should not exceed 1-2 mm beyond the surgical site Any edentulous areas can be filled in to make dressing continuous

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 Check Occlusion Dressing should extend only to the height of contour of the teeth It should not be in occlusal contact during closure

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Preparation & application of periodontal dressings

Repacking After the pack is removed, it is usually not necessary to repeat it. However in some condition it is advisable to repack for additional 1 week. The conditions arei. A low pain threshold value patients who are particularly uncomfortable when the pack is removed. ii. Unusual extensive periodontal involvement iii. Slow healing.

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CARE AFTER PERIODONTAL PACK

A periodontal pack placed over your gums to protect them from irritation. The pack prevents pain, aids healing, and enables you to carry on most of your usual activities in comfort. The pack will harden in a few hours, after which it can withstand most of the forces of chewing without breaking off; it may take a little while to become accustomed to it. The pack should remain in place as long as possible. After the operation avoid hot foods in order to permit the pack to harden Do not brush over the pack. Brush and floss normally the areas of the mouth not covered by the pack.

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 Use chlorhexidine mouth rinses after brushing After the pack is removed the gums most likely will bleed more than they did before the operation. This is perfectly normal in the early stage of healing

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The First Postoperative Week

Properly performed, periodontal surgery presents no serious postoperative problems. Patients should be told to rinse with 0.12% chlorhexidine gluconate (Peridex, PerioGard) immediately after the surgical procedure and twice daily thereafter until normal plaque control technique can be resumed. The following complications may arise in the first postoperative week, although they are the exception rather than the rule: i. Persistent bleeding after surgery ii. Sensitivity to percussion iii. Swelling iv. Feeling of weakness

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Removal of the Periodontal Pack and Return Visit Care

When the patient returns after 1 week, the pack is taken off by inserting a surgical hoe along the margin and exerting gentle lateral pressure. Pieces of pack retained interproximally and particles adhering to the tooth surfaces are removed with scalers. Particles may be enmeshed in the cut surface and should be carefully picked off with fine cotton pliers. The entire area is rinsed with peroxide to remove superficial debris.

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Care of the Mouth between Periodontal Surgery Procedures

Care of the mouth by the patient between the treatment of the first and the final areas, as well as after surgery is completed, is extremely important . These measures should begin after the pack is removed from the first operation. The patient has been through a presurgical period of instructed plaque control and should be reinstructed at this time. Vigorous brushing is not feasible during the first week after the pack is removed. However, the patient is informed that plaque and food accumulation retard healing and is advised to try to keep the area as clean as possible by the gentle use of soft toothbrushes and light water irrigation.

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 Rinsing with a chlorhexidine mouthwash or its topical application with cotton-tipped applicators is indicated for the first few postoperative weeks, particularly in advanced cases. Brushing is introduced when healing of the tissues permits it; the vigor of the overall hygiene regimen is increased as healing progresses. Patients should be told that there be more gingival bleeding will most likely occur than before the operation, that it is perfectly normal and will subside as healing progresses, and that it should not deter them from following their oral hygiene regimen.

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Management of Postoperative Pain

Dentinal hypersensitivity can be a challenging condition for patients to describe and dental professionals to accurately diagnose. It consists of short, sharp pain that occurs when a stimulus reaches exposed dentin. This stimulus is most commonly thermal, either hot or cold, but can also be tactile, chemical, or evaporative. Typically, no other pathology can be found for the pain associated with dentinal hypersensitivity. Patients may or may not report this painful and often chronic condition to their dentist or dental hygienist and when they do, they report experiencing short, sharp pain after a variety of stimuli.

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DESENSITIZING AGENTS
Desensitizing agents can be applied by the patient at home or by the dentist or hygienist in the dental office. The most likely mechanism of action is the reduction in the diameter of the dentinal tubules so as to limit the displacement of fluid in them. According to Trowbridge and Silver (1990), this can be attained by 1) Formation of a smear layer produced by burnishing the exposed surface, 2) Topical application of agents that form insoluble precipitates within the tubules, 3) Impregnation of tubules with plastic resins, or 4) Sealing of the tubules with plastic resins

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 The most common agents used by the patient for oral hygiene are dentifrices. Although many dentifrice products contain fluoride, additional active ingredients for desensitization are strontium chloride, potassium nitrate and sodium citrate. The following dentifrices have been approved by the American Dental Association for desensitizing purposes: Sensodyne, and Thermodent, which contain strontium chloride Crest Sensitivity Protection, Denquel, and Promise, which contain potassium nitrate and Protect,which contains sodium citrate.

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 Fluoride rinsing solutions and gels can also be used after the usual plaque control procedures. Prati C, Venturi L, Valdr G, Mongiorgi R (2002)

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 A newer method of treatment for hypersensitive dentin is the use of varnishes or dentin bonding agents to occlude dentinal tubules. Newer restorative materials,such as and glass-ionomer cements, dentine bonding agents, are still under investigation, but when the tooth needs recontouring or difficult cases do not respond to other treatments, the dentist may choose to use a restorative material. Resin primers alone could be promising, but the effects are not permanent and investigations are ongoing. (Prati C, Cervellati F, Sanasi V, Montebugnoli L, 2001)

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 Recently, attempts have been made to improve the success and longevity of these treatments using lasers. Low-level laser "melting" of the dentin surface appears to seal dentinal tubules without damage to the pulp. Nd:YAG laser has been used to coagulate fluoride varnish on root surface. (Kimura et al, 2000)

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HOSPITAL PERIODONTAL SURGERY

Ordinarily, periodontal surgery is an office procedure performed in quadrants or sextants, usually at biweekly or longer intervals. Under certain circumstances, however, it is in the best interest of the patient to treat the mouth in one operation with the patient treated in a hospital operating room under general anesthesia.

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 Indications for hospital periodontal surgery include: Optimal control and management of apprehension, Convenience for individuals who cannot endure multiple visits to complete surgical treatment, and Patient protection.

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Postoperative Instructions
After a full recovery from general anesthesia, most patients can be discharged home with a responsible adult. The effects of general anesthesia and sedative agents make the patient drowsy for hours, recommending adult supervision at home for up to 24 hours after surgery. The typical postoperative instructions should be given to the responsible adult and the patient should be scheduled for a postoperative visit in 1 week.

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Instruments used in periodontal surgery

Surgical procedures used in periodontal therapy often involve the following measures (instruments): Incision and excision (periodontal knives) Deflection and readaptation of mucosal flaps (periosteal elevators) Removal of adherent fibrous and granulomatous tissue (soft tissue rongeurs and tissue scissors) Scaling and root planing (scalers and curettes) Removal of bone tissue (bone rongeurs, chisels and files) Root sectioning (burs) Suturing (sutures and needle holders, suture scissors) Application of wound dressing (plastic instruments)

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Set of instruments used for periodontal surgery and included in a standard tray.

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The instrument tray

The instruments listed below are often found on such a standard tray: Mouth mirrors Graduated periodontal probe/Explorer Handles for disposable surgical blades (e.g. Bard- Parker handle) Mucoperiosteal elevator and tissue retractor Scalers and curettes Cotton pliers Tissue pliers

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Tissue scissors Needle holder Suture scissors Plastic instrument Hemostat Burs

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Additional equipment may include: Syringe for local anesthesia Syringe for irrigation Aspirator tip Physiologic saline Drapings for the patient Surgical gloves, surgical mask

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 Excisional and Incisional Instruments Periodontal Knives (Gingivectomy Knives) The Kirkland knife is representative of knives typically used for gingivectomy. These knives can be obtained as either double-ended or singleended instruments. The entire periphery of these kidney-shaped knives is the cutting edge.

Gingivectomy knives. A, Kirkland knife. B, Orban interdental knife.

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Interdental Knives The Orban knife #1-2 and the Merrifield knife #1, 2, 3, and 4 are examples of knives used for interdental areas. These spear-shaped knives have cutting edges on both sides of the blade and are designed with either double-ended or single-ended blades.

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Surgical Blades Scalpel blades of different shapes and sizes are used in periodontal surgery. The most common blades are #12D, 15, and 15C. The #12D blade is a beak-shaped blade with cutting edges on both sides, allowing the operator to engage narrow, restricted areas with both pushing and pulling cutting motions. The #15 blade is used for thinning flaps and general purposes. The #15C blade, a narrower version of the #15 blade, is useful for making the initial, scalloping-type incision. The slim design of this blade allows for incising into the narrow interdental portion of the flap.

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Surgical blades. Top to bottom, #15, #12D, and #15C. These blades are disposable.

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Surgical curettes and sickles

Larger and heavier curettes and sickles are often needed during surgery for the removal of granulation tissue, fibrous interdental tissues, and tenacious subgingival deposits. The Prichard curette and the Kirkland surgical instruments are heavy curettes, whereas the Ball scaler #B2-B3 is a popular heavy sickle. The wider, heavier blades of these instruments make them suitable for surgical procedures.

Prichard surgical curette.

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Periosteal Elevators The periosteal elevators are needed to reflect and move the flap after the incision has been made for flap surgery. The Woodson and Prichard elevators are well-designed periosteal instruments.
Woodson periosteal elevator.

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Surgical Chisels The back-action chisel is used with a pull motion, whereas the straight chisel (e.g., Wiedelstadt, Ochsenbein #1-2) is used with a push motion. Back-action chisel. The Ochsenbein chisel is a useful chisel with a semicircular indentation on both sides of the shank that allows the instrument to engage around the tooth and into the interdental area. The Rhodes chisel is another popular back-action chisel. Ochsenbein chisels are paired, with the
cutting edges in opposite directions.
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Tissue Forceps The tissue forceps is used to hold the flap during suturing. It is also used to position and displace the flap after the flap has been reflected. The DeBakey forceps is an extremely efficient instrument

DeBakey tissue forceps.

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Scissors and Nippers Scissors and nippers are used in periodontal surgery to remove tabs of tissue during gingivectomy, trim the margins of flaps, enlarge incisions in periodontal abscesses, and remove muscle attachments in mucogingival surgery.
The Goldman-Fox #16 scissors has a curved, beveled blade with serrations

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Needle holders Needleholders are used to suture the flap at the desired position after the surgical procedure has been completed. The Castroviejo needleholder is used for delicate, precise techniques that require quick and easy release and grasp of the suture.

Conventional needle holder

Castroviejo needle holder.

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Electrosurgery (Radiosurgery) Techniques and Instrumentation

Electrosurgery is the use of a high frequency electrical energy in the radio transmission frequency band applied directly to tissue to induce histological effects. (current is in the range of 1.5 -7.5million per second or megahertz) Four basic types of electrosurgical techniques areElectrosection Electrocoagulation Electrofulguration Electrodessication

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Electrosection-used for incision ,excision and tissue planing. Done with single wire active electrodes that can be bent or adapted to accomplish any type of cutting procedure. Electrocoagulation-haemorrhage control obtained by using the electrocoagulation current. Electrosection and electro coagulation are the procedures most commonly bused in all areas of dentistry. Electrifulguration and electrodessication are not in general use in dentistry.

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ADVANTAGES OF ELECTROSURGERY 1 Tissue separation is clean, with little or no bleeding. 2 A clear view of the surgical site is provided. 3 Planing of soft tissue is possible. 4 Access to difficult-to-reach areas is increased. 5 Healing discomfort and scar formation are minimal, 6 Chair time and operator fatigue are reduced. 7 The technique is pressureless and precise. (Johnson David Gnanasekhar, 1998)

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REFERENCES
Carranzas Clinical periodontology 10th edition Jan lindhe Text book of Clinical Periodontology and implant dentistry 4th edition Essentials of medical pharmacology- KD Tripathi Isabel C. C. M. Porto, Ana K. M. Andrade and Marcos A. J. R. Montes. Diagnosis and treatment of dentinal hypersensitivity. Journal of Oral Science, Vol. 51, No. 3, 323-332, 2009 K David, Shetty Neetha J, Prahlad Swati. Periodontal dressings: An informed review. J Pharm Med Sci 26(26): 269-272, 2013 Wray L. The diabetic patient and dental treatment: an update. Br Dent J. Sep 9 2011;211(5):209-15.

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REFERENCES
Wilson W, Taubert KA, et al. Prevention of Infective Endocarditis, Guidelines from the American Heart Association. A Guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasake Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc. 2007;138(6):739-45, 747-60. Smith A, et al. Management of infection control in dental practice. J Hosp Infect. J Hosp Infect. 2009;71(4):353-358. Shuman SK. A physician's guide to coordinating oral health and primary care. Geriatrics. 1990;45(8):47-57.

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REFERENCES
Electrosurgery in dentistry,Johnson David Gnanasekhar,Quintessence International,1998 William Becker, Burton E. Becker, Raul Caffesse. A longitudinal study comparing scaling and root planing, osseous surgery and modified Widman fprocedures: results after 5 years. J Periodontol 2001;72:1675-1694

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